NEW INSTRUMENTS IN PLASTIC OPERATIONS ON RENAL PELVIS AND URETER

AUGUSTUS HARRIS, M.D., F.A.C.S.

Assistant Clinica Professor of UroIogy, Long IsIand ColIege of Medicine; Attending Urologist, Long Island CoIIege, St. John’s and St. GiIes HospitaIs

BROOKLYN, N. Y.

0 those famihar with the surgery of T the kidney the ihustrations shown with legends are seIf-expIanatory.

The whoIe idea of the instruments is to min- imize the amount of actua1 gross injury to the kidney substance in pIastic operations, where a catheter “ spIint” is employed to advantage and aIso where nephrotomy drainage, in addition, is indicated.

To the Iate Dr. CharIes H. Peck1 be- Iongs the credit for introducing the idea of “spIinting the ureter” by catheter in operations upon the peIvis. The writer has referred to this advantage in a previous paper2 and has empIoyed it with much satisfaction during the past eight or nine years. LittIe reference has been made by others to Dr. Peck’s method excepting in recent pubIications.

We have found the instruments herewith presented very usefu1 and heIpfu1 during the past two years. Heretofore, surgeons have usuaIIy empIoyed the ordinary hemo- stat to perforate the kidney parenchyma in order to estabIish drainage from the peIvis. With the jaws opened, the usua1 hemostat spreads considerabIy within the kidney and causes an unnecessary Iacera- tion of the substance. We have noted, furthermore, that the fistuIous wounds of the kidney, after remova of the catheter “spIint” or drainage tube, appear to hea more quickIy. In fact, some wounds have faiIed to drain any urine in the Ioin foIIow- ing the removal of the catheter “spIint.”

The use of the instruments presented gives the operator an added feeIing of confidence, particuIarIy where the ureter is amputated and end-to-end suture to the peIvis empIoyed. With the ureteric catheter lying in position, as iIIustrated, for five to seven days after operative repair, it is

apparent that canaIization of the Iumen is more efficientIy maintained and that dis- tortion, kinking and stenosis at the uretero- peIvic junction is prevented during the earIier stages of healing. Nephrotomy drainage with catheter offers the advantage of reducing tension and increased pressure of urine on the peIvis and suture Iine and meets the factor of possibIe associated in- fection. It appears to be as IogicaI to divert the urinary stream in certain of these cases as in cystotomy when pIastic operations are done on the urethra. Ne- phrotomy drainage is much preferred to pyeIotomy drainage.

It has been shown by IseIin,3 in animaIs, that eversion of the mucous membrane of the ureter is the chief factor in causation of Iate stenosis after heaIing. The remova of any redundant portion of mucous mem- brane is, therefore, necessary in end-to-end suture. The work of IseIin tends to revoIu- tionize previous conceptions concerning the Iate effects on kidney function, of com- pIete division of the ureter. Further ex- perimental work in this IieId is most essentia1 and necessary. These matters have been more fuIIy discussed in a recent contribution.4

We beIieve the instruments shown here- with are of practica1 vaIue and wiI1 faciIi- tate successfu1 end-resuIts.

REFERENCES

I. PECK, C. H. Treatment of Obstructions of the Upper Ureter and Early Hydronephrosis. Ann. Swg., 83: 260-266, 1926.

2. HARRIS, A. Operative injury of the ureter. Am. Jour. Surg., 8: 80x-8og (April) 1929.

3. ISELIN, M, Surg. Gynec. and Ok., 49: 5o3-fog, Oct., 1929.

4. HARRIS, A. The probIem of non-calcuIous uretero- peIvic obstruction. Ann. Surg., 102: 6 (Dec.)

1935.

126 A merican Journal of Surgery Harris-PIastic

FIG. I. Six-inch kidney trocar with blunt conical tip introduced through incision in pelvis and forced through kidney substance at external border by way of lower calix; provides minimum trauma to renal substance.

FIG. ra. Detail of kidney trocar with handIe, obtura- tor partially withdrawn. The instrument is made in two sizes, one to admit a No. 6 F. siIk catheter or bougie, the other to admit No. 8 F. catheter or bougie.

FIG. 2. Obturator of kidney trocar completeIy with- drawn, with No. 8 F. silk catheter passed through lumen beyond handIe.

FIG. 3. After the remova of the trocar, distal end of No. 8 F. catheter is passed we11 down the ureter near bJadder, while the proxima1 end is brought out through the upper angIe of wound. This pro- vides adequate “splinting” of ureteropelvic junc- ture and avoids distortion and stenosis at site of plastic procedure.

Rena1 Operations OCTOBER, 1936

FIG. 4. New aIIigator forceps with six-inch shaft forced through kidney substance in manner simiIar to a trocar. No. 16 F. four-eyed rubber catheter, heId in jaws of forceps, about to be drawn into cavity of renaI peIvis. This minimizes kidney trauma when providing nephrostomy drainage.

FIG. 4a. Detail of aIIigator forceps with jaws open. Maximum caliber of forceps at hinge No. 16 F. Jaws aIways closed tightIy when passing through kidney substance.

FIG. 5. PIastic operation of ureteropelvic junction compIeted, incIuding partia1 resection of redundant pelvis; nephrostomy drainage tube and “catheter- spIint” in proper position. (Proximal ends brought out through incision.) “Catheter-splint” remains in situ for tive to seven days. Nephrostomy drain- age tube, advisable in a11 anastomotic procedures and often in other repair cases, remains in situ for five to six days.